Cardiac question

[Kaisu]

The patient is an 82 year old female with a chief complaint of palpitations. Originally exertion induced, they now occur at rest. Patient is a poor historian with cognitive difficulties. She states palpitations occur daily. Patient reports feeling nausea during the episodes, denies shortness of breath and/or diaphoresis.

Patient had mitral valve replacement 2 1/2 years ago, followed by implantation of an RV demand pacemaker.

Patient's ejection fractions have decreased steadily since the surgery, and she is now in heart failure. EJ of 61% after surgery, now at 34%. Patient has no coronary artery disease, is normo-tensive, with normal renal and hepatic function. Medications include coumadin, lasix and various supplements (primarily K-dur and Iron).

Patient's only other complaint is frequent constipation.

Patient has an underlying controlled afib with a ventricular conduction delay. Her paced beats have a complex of around 120 mmsec. Native beats are also wide, around 115 mmsec.

Now the question: Given the wide complex, if I am fortunate enough to capture an episode of tachycardia on the monitor, how can I tell if the tachycardia is atrial or ventricular in origin?

Thank you for any help you can give me.

[basejump]

Can you post the strip? Thanks.

[Kaisu]

Don't have a strip mate...

[DwayneEMTP]

Uhhh...yeah, in my case the thanks is premature...No idea.

How did you get so much information from a patient described as a poor historian? I've run on Drs that would give a poorer history... :-)

What is causing you to believe that her feelings of palps is secondary to runs of tachycardia as opposed to sets of PVCs?

The patient sounds to be in pretty good shape for her age. Any idea why she's in heart failure?

Sorry Babe...I know that none of this is why you posted...it just got me curious. Feel free to ignore if it queers your thread.

Dwayne

[Bieber]

There's three criteria to differentiating V-tach from other wide-complex arrhythmias.

1.) Is there extreme right axis deviation and upright V1? If so, V-tach.

2.) If V1 has an upright complex, is the morphology one of these three:

a.) Taller left peak than right "big mountain, little mountain".

b.) A single upright peak "steeple sign".

c.) A single peak with a slur "fireman's hat".

If so, V-tach.

d.) If V1 has a negative deflection, is there a fat R wave (>40 ms) or slurring or notching in the initial downward stroke (q or s wave)? If so, V-tach.

3.) Is there any negative deflection or a fat Q wave in a biphasic complex in V6? If so, V-tach.

Also, if they've ever had an MI before and if they've ever had tachycardia following the MI, the odds favor V-tach (86%).

This is all information I learned from reading the handout of the Multilead EKG by Dr. Bob Page.

Hope it helps!

Edited November 12, 2011 by Bieber

[Kaisu]

It helps some for sure Bieber... thanks for posting

To answer your questions Dwayne...

The patient's daughter had a file of pertinent reports and notes in chronological order. While the fire medics did the initial assessment I perused the file and asked questions of the daughter. The patient was a poor historian in that she could not provide consistent or reliable answers with regards to her episodes of "pounding heart", which was the current incident. The episode had passed by the time we were able to get there and get her on the monitor.

A run of PVCs lasting that long is by definition, my friend, V-tach. I have no way of knowing where it's polymorphic or monomorphic but V-tach it is..

No idea why she's in failure, but three possibilities come to mind

1 - during her open heart surgery there may have been a failure of cardiac preservation (around 5 hours for that to happen)

2 - RV pacemakers in patients with existing LV failure (that as far as I could tell was not the case with this patient as the mitral valve replacement/aortic valve repair was supposed to prevent heart failure) sometimes messes with the synchronocity of the heart and can be helped with placement of an LV lead

3 - ideopathic

and I love the questions. Anyone else please chime in and correct, instruct and inform.

[romneyfor2012]

With that history, it would not shock me to see a really freaky rhythm, but hard to say when I cant see it. Patients with that low of EF can have alot of non-textbook ectopy that does not fit "the rules".

Someone told me that Philips monitors have a hard time reading paced rhythms and makes a normotensive patient appear to be in VTach, but i have never used one.

[DwayneEMTP]

...A run of PVCs lasting that long is by definition, my friend, V-tach. I have no way of knowing where it's polymorphic or monomorphic but V-tach it is..

I didn't and don't see where you mentioned how long they last. And it's also why I said sets. I've commonly seen sets of PVCs that were not consecutive that made patients freak out. 8-10 a min or so, maybe more for short periods.

Unless you verified this by catching it with the monitor, or monitoring her pulse rhythm/quality manually during an episode, pt reported, and certainly patients daughter reported, palpitations combined with some minimal nausea and feeling weird, doesn't in fact V-tach make...so...

Neener neener Sweet Cheeks!

Yepp...chalk up another one for the boys...

Dwayne

[mobey]

I use 2 simple methods myself, since I have trouble remembering all the rules in the heat of the momemt at 3am (Though next time i'm calling bieber).

1) Are all the V leads concordant? (All positive or negative). If so.... prolly V-Tach

2) Is there right axis deviation? If so Prolly V-Tach

Consider thier "normal" rythm in this case. If they are a A-Fib look for regularity in your strip. Regular wide strip in a A-Fib patient strongly leans toward V-Tach.

If you are really unsure..... just use Amiodarone! Can`t go wrong

[Kaisu]

I didn't and don't see where you mentioned how long they last. And it's also why I said sets. I've commonly seen sets of PVCs that were not consecutive that made patients freak out. 8-10 a min or so, maybe more for short periods.

Unless you verified this by catching it with the monitor, or monitoring her pulse rhythm/quality manually during an episode, pt reported, and certainly patients daughter reported, palpitations combined with some minimal nausea and feeling weird, doesn't in fact V-tach make...so...

Neener neener Sweet Cheeks!

Yepp...chalk up another one for the boys...

Dwayne

You celebrate far too soon oh mighty mouth... If I wasn't relatively sure that these were in fact of longer duration than just short runs of PVCs I would have said so....

How many short runs of PVCs have you encountered that produced symptoms of nausea lasting for 10 - 15 minutes?

If you are really unsure..... just use Amiodarone! Can`t go wrong

I am an amiodarone fan myself... the other option is synchronized cardioversion. Electricity fixes any tachy dysrhythmia pretty fast. I just like to know what I am dealing with.